The second part of this, and this is a follow-up, is the whole issue of qualification. I know the president has talked about, and several prior secretaries have talked about, trying to reduce the timeframe that’s required to get through the enrollment process. What can you tell us about these efforts?

It’s gotten much better. I think it’s becoming quite streamlined. We want to make it very friendly and very non-bureaucratic. You’re absolutely right.

What other efforts would you say are going to be coming about as a result of this administration’s focus on veterans?

Well, we have a lot of special populations that are coming particularly out of the present conflict – traumatic brain injury [TBI], PTSD [post-traumatic stress disorder], etc. – our bread and butter, if you will. But the majority of our veterans have multiple complex, chronic diseases and they’re older. What we are trying to do with our new models of care is … to create a coordinated, coherent system of care for these people – veterans that have combinations of diabetes, congestive heart failure, obesity, chronic obstructive pulmonary disease, etc. I think that’s one of the major things that we’re going to be able to offer: this patient-centered, team care-based, continuously improving, new model of care that is centered around the needs of the patient, not around the needs of the institutions. We will be their advisors and consultants, but we’ll have them much more deeply involved in decisions about their care. We believe that we’re going to create a very attractive health care system and health care environment through these new models of care.

There are three signature health effects that seem to be coming out of this series of present-day conflicts – high rates of suicide, traumatic brain injury, and post-traumatic stress disorder. What treatments do you see emerging and what are you doing in the short and long term that you can talk about?

First of all is suicide. We have spent a tremendous amount of time and energy on addressing the suicide problem. First of all, we have suicide coordinators at every one of our medical centers. We have not only coordinators, but also a structured program primarily based on two things. One, educating the provider population about the issues surrounding suicide and its recognition, and two, providing case management for those who are seriously mentally ill, seriously depressed, and particularly who are at high risk for suicide. The second thing is that we’ve hired probably 6,000 new mental health providers in the last five years. Lots of people. The next thing is a suicide hotline that the VA established almost three years ago now, based in Canandaigua, N.Y., a hotline that receives almost 100,000 calls a year. We can attribute about 7,000 “saves” to this service, where they have definitely rescued people either from harming themselves or harming somebody else. It’s been a very successful thing. But the tragedy of it is that one suicide is too many. Even though we may be making progress, there is still more to be done. There’s also a fourth element. We’re cooperating with the Department of Defense to provide for a better transition for personnel between active duty and veteran status, and to provide more consistency in mental health treatment and diagnosis between active duty military and the VA.

The second issue you asked about was PTSD, and it has been recognized as one of the signatures of this particular conflict. The fact that many active duty soldiers are having multiple exposures to combat puts them at higher risk, not just for PTSD but also for anxiety, depression, and other mental health disorders. Probably the rate is somewhere between – of developing PTSD and a series of mental health problems – is between 10 and 15 percent. We don’t really know the detailed rates for sure yet, but it’s around that. Everybody has PTS – that is post-traumatic stress – who’s been exposed to combat. You would be inhuman if you didn’t get tremendously stressed. The job, in my mind, in part is to prevent people from developing post-traumatic stress disorder, which is a very different, long-term medical care kind of problem. Dealing with that exposure to that trauma early is very important.

Remember, these are our kids. They’re 18 to 20 years old in many instances. They’re invulnerable, they’re immortal – at least they think of themselves that way. For them to admit that this might be a problem, they might have difficulties, it’s very hard to get them to admit and then get them into any kind of treatment. The military is doing, I think, a very good job now of trying to identify those people who need to have further help. Of course, when they’re discharged, that becomes an issue for us. Everybody knows that the sooner you can identify someone with post-traumatic stress, the sooner you can get them into treatment, the more likely you are to avoid the long-term consequences of social disruptions, the chemical dependency, the divorces, the financial difficulties, all that sort of stuff. So, we want to get these people early. With this conflict, we’re doing a much better job of getting people involved with the VA than we’ve ever done before. Presently, about 46 percent of the discharged combat veterans are actually enrolling with us, which is a very high number. A very high number. We want more. We’d like to touch every one of them. Another important part of this is that every one of these returning combat veterans who sees us is screened for depression, screened for PTSD, screened for traumatic brain injury – mild or moderate – and screened for chemical dependency. If we see these young veterans, we can identify those people who may need further help.

 

That data collection has got to be giving VHA great value in terms of both predictive analysis and screening.

It will certainly be helpful with the predictive analysis and it’s been paying off right now in terms of screening.

A quick follow-up. A couple of years ago I got a look at the then-current edition of The Long Road Back, the VA data annex about PTSD, and what struck me was the very large number of people who wouldn’t even allow themselves to be screened. What are you doing to try to coax these people in to be screened, and if they show signs, to get them into treatment and into support under your system?

We’re doing several things. One is that with the National Guard and the Reserve, we’re going to their units at 30, 60, 90, and 120 days following deployment returns, and putting on programs about PTSD, about other mental health problems. About what their expectations are going to be post-combat, not only for their soldiers, but for their families. What you need – and this is being done for active duty personnel as well – you need families educated about what the consequences of combat can be, what the signs [are] of somebody having trouble coping with their post-trauma experience, who can talk to the veteran or to the soldier and encourage them to get in. You need physicians in private practice who deal with these young soldiers to be aware of what they should be looking for, and we’re putting on educational programs in the states for physician communities.

What you really want to have is a whole village, if you will, that is tuned in to these potential problems and these needs, and that knows how to help, that knows what to look for, and knows where somebody can go to get help. You know that old expression, “It takes a village to raise a child?” Well, it takes a village to cope with all of these results of being in combat. It’s not just any one individual’s responsibility or organization, but everybody’s got to be alert and aware, who knows what the signs are, and who knows where to go. We’re trying to make a better-educated public, a better-educated provider community, and a better-educated family.

As we sit here, it’s the summer of 2010. What is the current state of clinical thinking on TBI, from your point of view at VA? What is the current state of medicine in helping deal with it and mitigating the effects?

First of all, I’m not an expert in TBI. I know it from my present position, but of course we have [Dr.] David Cifu, the director of that program, who is much more knowledgeable than I am. Let me give you a little bit of my perspective. First of all, in terms of our system, we’ve got the four polytrauma centers and the fifth on the way. They are located in Palo Alto [Calif.], Minneapolis [Minn.], Richmond [Va.], and Tampa [Fla]. All of them absolutely excellent places. So far, since March 2003, we’ve treated 1,836 patients in those units. It’s not a huge number of people, but they are incredibly, severely injured. One of the things one needs to remember is that these kids are likely going to live to be 70 or 80 years old. So they’re going to be our responsibility for another 50 or 60 years, at least.

Are you still looking at about half of the serious polytrauma patients coming from noncombat-related injuries?

That’s correct. About … 778 of them were injured in a military theater of operations. 1,058 were injured in noncombat, nondeployed incidents. Now, every VA medical center has expertise in polytrauma. We have what we call network or division polytrauma centers. For example, Washington would be the polytrauma center for that division. Minneapolis would serve it for Network 23. Those places that don’t have a polytrauma center near them, they have a center that has some substantial expertise while it’s not a polytrauma center. Then again, there is at each of the medical centers expertise in polytrauma.

The idea is to be able to get the injured veterans back as close to normal as possible. So, we want the capacity to manage them once they’ve been rehabilitated at many of our locations. But frankly, we’ve been incredibly successful. For a cadre of about 870 former patients, 781 of them are living in private residences. That’s 89 percent. It’s incredible. And 73 percent of them live alone or live independently. 206 are employed, 90 are in school part- or full-time, 59 are looking for jobs or performing volunteer work. It’s been a remarkably successful program when you think about it. Now, there are some severely injured people who just absolutely cannot be brought back to anything that resembles a normal life. The amazing thing is, we can treat most of those people in their homes. With the support of families and with as much supportive care as we can muster in the community to bring in, they’re able to stay home, which is a very important part of this, to be cared for at home.

Let’s talk a little bit about VHA and how it’s doing right now.

Let me give you a couple of things. This is basically a great system. I mean, this is a great system. We’re the largest integrated medical delivery system in this country. We have the best integrated mental health system in this country. Nobody has the breadth and depth of mental health services available to them that we have. We are also the largest medical educator in this country. Nobody does more clinical medical education than we do. Not just medical students, but nurses, LPNs, and all kinds of people in health care. And we have this incredible reputation for quality and safety. We’ve really done an excellent job – not a perfect job – of dealing with these returning veterans. A higher percentage of them are enrolled with us than in any other conflict before. I think when people look back and see how well we handled Vietnam and its aftermath and here, they’re going to say we’re doing a better job. So, it’s a great system. No question about it. But it’s not as good as it needs to be and it’s not as good as it can be. That’s what I am all about. We need to be better. We can be better, and we need to be better.

Let’s talk about “better” real quickly. Do you have the capacity you need right now to deal with the patient loads, and do you feel like you’re going to be projecting that capacity out into the follow-on years?

Oh, definitely we have the capacity. We’ve had two very generous budget years. As an example, I mentioned before that we’ve hired, since either year FY 03/04, about 6,000 additional mental health providers. So yes, unquestionably we have the capacity, but we could be more efficient. We can do a better job with access. When we get our primary care medical care system reorganized, we’re going to have better capacity, I think, than what we’ve got now. There are efficiencies that we can make in many different areas. There’s still more of the work that we do as an in-patient that we can move slowly to the outpatient arena where it’s done more cost-effectively. So, do we have the capacity? Absolutely. Do we have further efficiencies that we need to achieve? Absolutely!

Let’s discuss electronic health records, which people talk about in an almost “silver bullet” fashion. How is the ongoing effort to create an electronic health record going, and how are your efforts to build a common electronic health record going with the folks over at TriCare and Department of Defense?

We at VA have an outstanding electronic health record. There’s no question about it. I think that for several years, the further development of it was a bit stalled as the Office of Information Technology was reorganized and centralized. With the advent of Roger Baker, the new assistant secretary for [information technology], there’s been a real new breeze blowing through the organization, where I think we’re seeing tremendous cooperation between the Office of Information and Technology and VHA in trying to move us forward, trying to continue the development and evolution of our electronic medical records. So, I’m very optimistic that we’re going to be able to stay on the cutting edge of informatics in health care. On a personal and professional basis, I think Roger’s been a wonderful person to work with. The spirit of cooperation, collaboration, and interplay is very heady and high. I think if you talk to many in VHA … they would tell you that there’s much progress being made now in development and in moving VA IT forward.

How is your funding base looking in the Congress over the next few years?

Our funding base looks very good. The financing of the [VA] is a bipartisan issue and we have had bipartisan support, and certainly very strong support from this administration for veterans and veterans’ issues. Very strong support. You’re always interested and concerned about what next year’s budget is going to be. We all know that the economy is tough and that people are going to be looking very carefully at all federal spending. Am I interested and concerned? Yes. Am I worried that the bottom’s going to fall out? No. There will be adequate funding for veterans and veterans’ health in the future. I’m very confident.

You talked earlier about VA being a big educator of medical personnel, but a lot of people also don’t know it’s one of the primary medical research entities in America and in the world, too. What new trends and technologies and processes do you see emerging out of VA in terms of medical research and development over the next few years? What are some of the things that you look at with a certain amount of excitement and interest?

A little bit of background first. VHA’s direct research budget is about $540 million. The indirect support of research is about the same amount, $500 million. So, we’re talking about a billion dollars in this organization that’s being devoted to research. This is probably second only to the National Institutes of Health in terms of the total amount of money being spent by a single organization on research. It’s huge. We’re also probably the best and largest health-services delivery research organization in the country. By that I mean people who look at the different kinds of therapies and particular diseases, different ways to approach it, and compare this way to that way and decide on what the best kind of therapy is, because we do a tremendous amount of work there. Over $250 million is devoted to that effort. We are a huge national resource when it comes to research.

The trends that I see in the future are: One, I think there’s going to be more comparative effectiveness research, that is comparing this way and that way and arriving at the best way. Two is that we’re going to be organizing an effort in deployment-related health problems. Research will be hiring a director of deployment-related research, where we are going to look specifically and more directly at PTSD, TBI, other mental health problems, exposures, all of those things that are a consequence of having been deployed and particularly [having] been deployed in combat. We’re going to develop a larger portfolio of deployment-related research. If I were going to talk about something for the future, that’s going to be a major change that we see, a major improvement.

How are you doing at recruiting and holding on to personnel?

Recruitment and retention vary around the country a little. As a whole, our turnover rates are very low. We generally do not have problems, except in some isolated areas, with recruitment. This is a great place to work. It’s a tremendous environment. We’ve got an inspired mission to provide for the health and well-being of America’s veterans, their heroes. We have got a good infrastructure and a very good organization. We don’t have a lot of trouble recruiting. There may be some very rural areas where we have trouble attracting certain kinds of physicians and what not, but in general, recruitment is not an issue for us.

Like your recruiting television commercials.

“One Thing Wonderful?” Those three commercials were just wonderful, I thought. They were everywhere. I mean, everywhere we looked, I saw those commercials. There’s a new series that’s going to come out this late fall. I did like them. I thought they were very well done.

Given what you and your counterparts over at TriCare have learned over decades of services now, what do you see that you have to offer the emerging health care systems that are going to be coming out of that national health care bill? What can you add that will make that transition and that building of that system easier, better, and more efficient?

I would say three things. One is that we are a demonstration of the benefits … which can be accomplished within an integrated delivery system where the providers, the medical centers, all work for the same organization. I think we’re an excellent example of how well that works. Two is that we’re a very good example of the kinds of benefits and actual cost savings you can wring out of an electronic health record. Three is that we are becoming an excellent example of a delivery system that has developed a care system for people with multiple, complex, chronic diseases; the older veteran, the veteran who really makes up the bulk of our population. I think we can demonstrate to the country … this new model of care – this new, better, more patient-centered way of caring for patients. So, I think those three things at least we have to offer.

Let me finish by making just a general statement. As I said earlier, this is an excellent system, but we’re not perfect, and we’re not as good as we need to be, nor are we as good as I think we can be. I see this moment in time as an excellent opportunity. We’ve got this great reputation. We’ve got an incredibly supportive administration. We have a very talented group of people. We’ve got this loyal veteran population. Health care reform is in the air, and if we don’t capitalize on this moment to really take a giant step forward in terms of how we do our care, how we do our business, it would be a pity. This is just an outstanding chance and I hope we grab it and really make something out of it.

How much do you love taking care of veterans?

I love taking care of veterans. I love this job and I love this organization. This is a great organization. I’m just so thrilled to see it where it is now and I am thrilled to see this prospect of really moving forward. I feel so incredibly fortunate to have been given the opportunity to participate in this.

This article was first published in The Year in Veterans Affairs and Military Medicine: 2010-2011 Edition.